Public Charge Questionnaire

Forms and Documents

Document Name	Status
Form DS-5540 Public Charge Questionnaire Form and Instruction	New
Signed Letter to Administrator Ray.pdf Supplementary Document	2020-02-20
11035_PublishedFR_02-12-2020.pdf Supplementary Document	2020-02-20
DS-5540 Legal Authorities.docx Supplementary Document	2020-02-20
DS5540 Emergency PRA Supporting Statement.docx Supporting Statement A	2020-02-20

IC Document Collections

IC ID	Document Title	Status
240038	Public Charge Questionnaire Form and Instruction	New

ICR Details

OMB Control No: 1405-0234	ICR Reference No: 202002-1405-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Public Charge Questionnaire
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/20/2020
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/20/2020
	Date Received in OIRA: 02/20/2020
Terms of Clearance: State is approved to collect information on this form beginning 12:01AM on 2/24.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	6 Months From Approved
Responses	397,814	0	0
Time Burden (Hours)	1,790,163	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Department seeks to better ensure that aliens subject to the public charge inadmissibility ground are self sufficient and will not rely on public resources to meet their needs, but rather, will rely on their own capabilities, as well as the resources of sponsors. Through the DS–5540, the Department will collect information in a standardized format regarding applicants’ ability to financially support themselves following entry into the United States, without depending on government assistance. Fields primarily pertain to the applicant’s health, family status, assets, resources, financial status, education, skills, health insurance coverage, and tax history. The DS–5540 would also require applicants to provide information on whether they have received certain specified public benefits from a U.S. Federal, state, local or tribal government entity.

Emergency Justfication: The Department of State requests OMB emergency processing of the DS-5540, Public Charge Questionnaire, pursuant to the process established in 5 CFR 1320.13. Section 212(a)(4)(A) of the Immigration and Nationality Act ("INA") provides that "any alien who, in the opinion of the consular officer at the time of application for a visa, or in the opinion of [a Department of Homeland Security ("DHS") officer] at the time of application for admission or adjustment of status, is likely at any time to become a public charge is inadmissible." The Department' of State ("Department") published an interim final rule ("IFR") on October 11, 2019, amending the standards in 22 CFR 40.41 for interpreting and applying the public charge visa ineligibility. The rule is intended to align the Department's standards with those of DHS, to avoid situations where a consular officer will evaluate an alien's circumstances and conclude that the alien is not likely to become a public charge, only for DHS to evaluate the same alien when he or she seeks admission to the United States on the visa and find the alien inadmissible on public charge grounds under the same facts. On January 27,2020, the Supreme Court lifted the nationwide injunction on DHS's public charge rule. U.S. Customs and Border Protection ("CBP") will begin implementing the DHS rule on February 24, 2020, except for in Illinois, where the rule remains enjoined. Pursuant to 5 CFR 1320.13, the Department has determined that this collection is needed prior to the expiration of periods normally associated with a routine submission for review under the provisions of the Paperwork Reduction Act, that this information collection is essential to the mission of the Department, and public harm is reasonably likely to result if normal clearance procedures are followed. The information is needed by the Department to enforce the public charge inadmissibility ground and facilitate legitimate travel to the United States. If the Department were not able to collect this information, it could result in an individual being granted a visa under the Department of State's public charge standard only to arrive at the port of entry to be found inadmissible on public charge grounds under DHS's newly implemented public charge standard. By collecting this information in time to implement the new public charge standard at the same time as DHS, this harm will be minimized.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 7142	10/24/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 8087	02/12/2020
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Public Charge Questionnaire	DS-5540	PUBLIC CHARGE QUESTIONNAIRE

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	397,814	0	0	397,814	0	0
Annual Time Burden (Hours)	1,790,163	0	0	1,790,163	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New Collection.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/20/2020

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